Atypical Radiographic Findings Research Articles

Artrite da gota tofácea crônica mimetizando artrite reumatoide

A gota é um distúrbio no metabolismo das purinas, usualmente associado à ocorrência de crises recorrentes de artrite nas articulações dos membros inferiores em homens entre 40-50 anos, e com o desenvolvimento de tofos subcutâneos nos pacientes com doença de longa evolução. Casos de pacientes com artrite gotosa crônica que mimetizam quadros de artrite reumatoide e vice-versa são raros. Descrevemos o caso de um paciente de 56 anos, com quadro de artrite poliarticular, simétrica e deformante, comprometendo principalmente as articulações de mãos e punhos, com nódulos subcutâneos difusos pelo corpo, alterações radiográficas atípicas e urolitíase, que, após avaliação clínica e dos exames complementares, recebeu diagnóstico de gota tofácea crônica mutilante mimetizando artrite reumatoide.

Limited Value of Adrenal Biopsy in the Evaluation of Adrenal Neoplasm

To determine the value of percutaneous adrenal biopsy in the evaluation of adrenal neoplasm. Retrospective review. Tertiary referral center. All adult patients undergoing image-guided adrenal biopsy from 1997 to 2007. Main Outcome Measure Biopsy sensitivity for malignancy. There were 163 biopsies performed on 154 patients. Mean (SD) age was 66 (12.5) years. Eighty-eight biopsies (53.4%) were performed in patients with a prior diagnosis of cancer. Forty-five (26.4%) were performed when imaging study results suggested previously undiagnosed cancer with a simultaneous adrenal metastasis. Thirty (20.2%) were performed for isolated adrenal incidentalomas. Rates of positive biopsy results in these 3 groups were 70.6%, 69.0%, and 16.7%, respectively. Prebiopsy evaluation for pheochromocytoma was performed in less than 5% of patients with established or suspected nonadrenal malignancies and 32% of patients with incidentalomas. In patients with isolated adrenal incidentaloma, a radiology report recommended biopsy 33% of the time for characteristics inconsistent with benign adenoma. Benign incidentalomas measured mean (SD) 4.2 (2.1) cm (range, 1.4-10.7 cm), and malignancies measured mean (SD) 9.3 (3.3) cm (range, 5.3-14 cm) (P < .05). All incidentalomas 5 cm or less (n = 18) were benign. There were 4 false-negative biopsy results: 3 adrenocortical carcinomas and 1 pheochromocytoma. Biopsy is unhelpful in patients with isolated adrenal incidentaloma. Despite atypical radiographic findings, all nonfunctioning nodules 5 cm or less were benign. The negative predictive value is unacceptably low and cannot be relied on to rule out malignancy. The value of biopsy remains the diagnosis of metastatic carcinoma in patients with a nonadrenal primary malignancy, proven by the more than 70% positive rate in this group.

Pulmonary sequestration: Report of three cases

Pulmonary sequestration is a non-functioning pulmonary parenchyma that is separated from tracheobronchial tree and receives its blood supply via systemic arteries. The diagnosis of sequestration pulmonis is based on clinical symptoms and characteristic radiologic findings. In this report, radiological findings of pulmonary sequester in three patients with non-resolving pneumonia were retrospectively reviewed. All patients underwent chest x-ray, computerized tomography of thorax and angiography. X-ray revealed in all cases tumorlike, unsharply bordered shadows in the posterior basal parts of the lung, two on the right and one on the left side. Computerized tomography (CT) finding showed solid-cystic tumor masses and angiography revealed anomalous blood supply from systemic arteries arising from aorta and running to the shadow in the lung. This finding is typical of bronchopulmonary sequestration. All patients were operated on and histological analysis of operative material confirmed diagnosis of intralobar pulmonary sequestration. Sequestration pulmonis can cause a diagnostic problem due to unspecific symptoms and atypical radiographic and CT findings. Therefore, it is important to demonstrate the arterial supply and venous drainage of the sequestered segment preoperatively. Today, with the help of non-invasive imaging techniques such as CT and magnetic resonance imaging (MRI), preoperative diagnosis of pulmonary sequester can be made easily, so, invasive techniques such as angiography are not required frequently.

Two cases of osteosarcoma showing atypical radiographic findings

Two cases of osteosarcoma showing atypical radiographic findings

Radiological Findings of Lung Cancer: Focus on Atypical Pattern

The clinical and radiographic findings of lung cancer have been well established many journals. Even if the radiographic findings of lung cancer show a typical pattern, the specific cell type of lung cancer sometimes needs to be determined prior to a pathological diagnosis. For example, the usual finding of a squamous cell carcinoma is similar to other cancer types such as an adenocarcinoma or a small cell carcinoma but with a lower incidence. Therefore, it should not be used to make a diagnosis of the cell type prior to a pathological diagnosis. Many unusual findings of lung cancer, so called atypical pattern have been reported, but atypical findings are widely accepted. The more important thing is not to diagnose a specific cell type of cancer but to differentiate it from other benign conditions such as tuberculosis, fungal infections or organizing pneumonia. This paper presents typical information of the cell type of lung cancer along with the atypical radiographic findings.

INFLAMMATORY FIBROBLASTIC PROLIFERATION OF THE RETROPERITONEUM PRESENTING AS A MALIGNANT PANCREATIC MASS

We report a case of a 75 year-old female who presented with vomiting, bloating, and epigastric discomfort. She reported a recent 15 pound weight loss following a laparoscopic cholecystectomy performed one month prior. Physical examination was unremarkable: the patient was afebrile with stable vital signs and a benign abdominal examination. Laboratory assessment revealed an elevated serum alkaline phosphatase with otherwise normal liver chemistries. The complete blood count was also normal. An abdominal plain film demonstrated dilated loops of small bowel, and a follow-up abdominal CT scan revealed minimally dilated small bowel with no point of obstruction, as well as a 6 cm × 4 cm pancreatic mass that encased the mesenteric vessels. The presence of the mass was confirmed with an abdominal MRI that also showed a mass encasing the superior mesenteric artery and vein. Tumor markers, including CA 19–9 and CEA, were normal. The patient underwent EUS-guided fine needle aspiration of the mass followed by a core biopsy under CT guidance and ultimate staging laparotomy. Histologically, the tumor was composed of poorly defined fascicles of plump spindle cells enmeshed within a collagenous stroma, most consistent with an inflammatory fibroblastic proliferation. There was no mitotic activity and no cytologic atypia. CD-34, C-kit, and ALK-1 immunohistochemical stains were negative, supporting this interpretation. This case is an example of an entity previously described as an “inflammatory pseudotumor,” with atypical radiographic findings suggestive of a pancreatic malignancy. The primary pathologic differential diagnosis includes a neo-plastic inflammatory myofibroblastic tumor which can appear similar histologically, but is frequently associated with expression of ALK-1 (anaplastic lymphoma kinase-1), a tyrosine kinase. Distinguishing between these two entities is clinically important because inflammatory fibroblastic proliferations are inherently benign, non-neoplastic lesions that likely represent an exuberant repair response to injury, whereas inflammatory myofibroblastic tumors are true neoplasms at risk for local recurrence and, rarely, metastasis.

Unusual MRI findings of hypertrophic pachymeningitis with irregular dural thickening and severe brain oedema

We report atypical radiographic findings of irregular dural thickening associated with severe brain oedema and compression of the frontal lobe in a 79-year-old man who had a previous diagnosis from tuberculosis that was complicated by diabetes mellitus. The patient was admitted because of deterioration of dizziness, loss of appetite, and dehydration. Magnetic resonance imaging (MRI) revealed hypertrophy of the dura mater along the left frontal lobe. To obtain a correct diagnosis, we biopsied the left frontal dura mater. Pathologically thickening of the dura and lymphocyte infiltration were observed. The patient was given a small dose of corticosteroids to the dural thickening. Although the thickening lessened and the oedema in the left frontal lobe of the brain was ameliorated, the patient’s general condition remained poor, and tuberculosis became evident. He was transferred to another hospital for treatment of the tuberculosis. The radiographical findings associated with hypertrophic pachymeningitis are discussed and the literature is reviewed.

Clinical analysis of recent lower lung field tuberculosis.

Because the incidence of lower lung field tuberculosis has recently increased in our affiliated hospitals, we carried out an analysis of its clinical characteristics during the past 10 years. We experienced 15 patients (7.5%) with lower lung field tuberculosis among 201 patients treated between April 1992 and March 1997, and 27 patients (11.1%) with the same condition among 243 patients treated between April 1997 and March 2002. The changes in clinical characteristics shown in the later period were as follows: (1) an increase in the percentage of elderly patients, (2) an increase in the incidence in patients who had received corticosteroid drugs for underlying disease, (3) atypical radiographic findings, such as homogeneous shadows resembling bacterial pneumonia, (4) an increase in microbiologically smear-positive patients, because more bronchoscopic examinations were performed, and (5) a high mortality rate (21.7%) with the increase being due to complications. Because there is a significant problem with nosocomial infections, patients with homogeneous shadows resembling bacterial pneumonia on admission should be examined for acid-fast bacilli containing Mycobacterium tuberculosis. We consider this problem to be not so difficult considering the progress in diagnostic methods for M. tuberculosis.

Clinical analysis of pulmonary Mycobacterium avium complex disease in association with corticosteroid treatment.

We studied the clinical characteristics of nine patients with pulmonary Mycobacterium avium complex disease occurring in association with corticosteroid drugs collected from our associated hospitals during the past 6 years. The average age of the nine patients was 62.2 years and the male/female ratio was 3 : 6. Regarding underlying disease, respiratory diseases existed in four of the patients and nonrespiratory diseases in the other five patients. The duration of corticosteroid treatment ranged from 5 months to 5 years, and the total dose of corticosteroid drugs ranged from 1.78 to 43.20 g. Pulmonary Mycobacterium avium complex disease was detected by clinical symptoms during corticosteroid treatment in six patients, and purified protein derivative was positive in three of eight patients tested. Radiological findings showed an infiltration shadow without cavity and bronchiectasis in the lower lung field. Microbiological examination was smear-positive in three patients, and the isolated mycobacterium was Mycobacterium intracellulare in five patients and Mycobacterium avium in four. Tolerance was shown to all antituberculous drugs, except for clarithromycin, in all patients. Although treatment including clarithromycin was performed for seven patients, the sputum conversion rate was 33% and an improved clinical effect was noted in only one patient. No change occurred in four and worsening occurred in four. Attention should be paid to the clinical symptoms and radiological findings of patients who have received corticosteroid drugs over a long period of time, because pulmonary Mycobacterium avium complex is characterized by atypical radiographic findings with no relationship to the total dose or duration of the administered corticosteroid drugs.

Clinical analysis of pulmonary tuberculosis in association with corticosteroid therapy.

Due to the increased incidence of pulmonary tuberculosis in association with corticosteroid therapy during the last five years in our associated hospitals, we studied the clinical characteristics of these patients. Fourteen cases of pulmonary tuberculosis were collected which occurred in association with corticosteroid drugs in our associated hospitals during the last 10 years; four patients (2.1%) from April 1991 to March 1996 and 10 patients (4.3%) from April 1996 to March 2001. The average age of the 14 patients was 74.1 years old and the male:female ratio was 9:5. Regarding underlying diseases, respiratory diseases (7 patients) were the most frequent and a past history of pulmonary tuberculosis was recognized in six patients. The duration of corticosteroid administration ranged from two months to seven years and the total dose of corticosteroids ranged from 1.20 g to 12.05 g. Pulmonary tuberculosis was detected by chance during a health examination in eight patients and radiological findings showed an infiltration shadow without cavity located in a portion other than the predominant location in four patients. A microbiological examination was smear positive in eight patients but tolerance was not shown to any antituberculous drugs. The prognosis was poor because the mortality rate was high, but the cause of death was not related to the progress of pulmonary tuberculosis. Careful observation of patients is considered to be important because pulmonary tuberculosis in association with corticosteroid drugs was found among inpatients, there was no relationship to the total dose or duration of administration of corticosteroid drugs, there were no clinical symptoms, and the patients exhibited atypical radiographic findings.

Intrarenal bacillus Calmette-Guérin therapy for carcinoma in situ of the upper urinary tract: long-term follow-up and natural course in cases of failure.

To assess the long-term efficacy of intrarenal bacillus Calmette-Guérin (BCG) therapy for the treatment of cytologically diagnosed upper tract carcinoma in situ (CIS) and report the time course in cases of failure. Fourteen renal units in 11 patients cytologically diagnosed as having upper urinary tract (UUT) CIS were treated with intrarenal BCG instillation. The BCG solution was administered by retrograde ureteric catheterization weekly for 6 weeks. Seven units were radiologically and cytologically free of disease at a median follow-up of 60 months. Two units which showed an initial response had recurrence with ipsilateral UUT CIS. The remaining five units did not respond to BCG. Of seven units with an initial negative response or recurrent UUT CIS, nephroureterectomy was undertaken in one because of coincidental renal cell carcinoma. In four of the remaining six units, invasive pelvic tumour developed at a mean follow-up of 20.5 months after the final instillation. Computed tomography showed wall thickening of the renal pelvis in two and mass-forming tumour in the renal parenchyma mimicking renal cell carcinoma in two. In three of these four cases, retrograde pyelography did not show typical findings of renal pelvic tumour, e.g. filling defect, infundibular obstruction or stenosis. Intrarenal BCG is effective in the treatment of UUT CIS in a long-term follow-up. In cases with a poor response or ipsilateral recurrence of CIS, there is a high risk of developing invasive tumour. Close follow-up using computed tomography is recommended because of the atypical radiographic findings of such tumours.

Hydropneumothorax: an unusual presentation/complication in community-acquired pneumonia

Community-acquired pneumonia continues to be a significant source of morbidity and mortality in the United States of America. This case shows one of the many ways in which patients may present to the emergency department physician or general practitioner in a clinic. The majority of patients present with typical clinical and radiographic findings. We present a case in which the patient presented with typical clinical findings but atypical radiographic findings which were suggestive of other clinical diagnoses. The rarity and severity of this case should highlight the importance of maintaining a high degree of suspicion for typical organisms, even when less common pathogens are suspected.

Pneumocystis carinii Pneumonia With an Atypical Granulomatous Response

Pneumonia due to Pneumocystis carinii may present atypical radiographic and pathologic findings. We report the case of a 32-year-old man with acquired immune deficiency syndrome (AIDS) whose chest roentgenogram showed a bilateral diffuse nodular pattern suggestive of miliary tuberculosis. Diagnosis ultimately required open lung biopsy, which showed evidence of an atypical granulomatous reaction with Pneumocystis carinii in the absence of other organisms. P carinii pneumonia must be considered in the differential diagnosis of patients with AIDS with nodular pulmonary densities and evidence of an atypical granulomatous reaction on pathologic specimens.

Unusual manifestations of head trauma.

Head injury is the leading cause of death in young adults. More than 2 million head injuries occur each year in the United States. Accurate and rapid diagnosis is imperative for the successful management of the trauma patient. The radiologic findings of common manifestations of head trauma have been well described; however, the patient who presents in the post-traumatic period with atypical radiographic findings is at risk for misdiagnosis and delay in treatment. In this essay, we illustrate some unusual findings in head injury that may complicate diagnosis.

Utility of the Gallium-67 Citrate Scan for the Early Diagnosis of Tuberculosis in Patients Infected with the Human Immunodeficiency Virus

Diagnosis of tuberculosis in patients infected with the human immunodeficiency virus (HIV) is sometimes difficult because of atypical clinical and radiographic findings. The aim of this retrospective study was to determine the utility of a gallium-67 citrate scan (67Ga scan) of the chest for the early diagnosis of tuberculosis in patients infected with HIV. We selected 174 67Ga scans performed as a part of the clinical evaluation of 145 HIV-infected patients with normal pulmonary parenchyma (seen on chest radiographs) and fever of unknown origin. Scans were evaluated as to whether there was uptake in lymphoid regions (a positive 67Ga scan) or not (a negative scan). Tuberculosis was the most common condition associated with a positive 67Ga scan (48[72.7%] of 66 positive 67Ga scans). Nodal uptake had a 72.7% positive predictive value and a 92.6% negative predictive value for tuberculosis. In our experience, 67Ga scanning is a useful tool for the clinical evaluation of HIV-infected patients with unexplained fever. In areas with a high prevalence of tuberculous infection, a 67Ga scan of an HIV-infected patients that shows nodal uptake allows the clinician to initiate prompt empirical antituberculous therapy while waiting for culture results. Conversely, a 67Ga scan that does not show nodal uptake makes the diagnosis of tuberculosis unlikely.

Cerebral infarction during hypertensive encephalopathy: Case report with pathologic and atypical radiographic findings

Neuroimaging of patients with hypertensive encephalopathy frequently reveals white matter changes that reverse with control of blood pressure. We report a young woman who presented with hypertensive encephalopathy but with unusual radiographic findings. Her course and atypical appearance on magnetic resonance imaging raised suspicion for encephalitis, but autopsy disclosed a large cerebral infarction, an uncommon complication during this clinical syndrome. The discovery of a pheochromocytoma at autopsy was also unexpected and may be associated with the unusual features of this case. The clinical, pathologic, and radiographic descriptions of this case may offer further insight into the pathophysiology of hypertensive encephalopathy.

Lobar Atelectasis: Typical and Atypical Radiographic and CT Findings

Lobar Atelectasis: Typical and Atypical Radiographic and CT Findings

Radiographic findings in pulmonary tuberculosis: the influence of human immunodeficiency virus infection

The chest radiographs and medical records of 166 patients diagnosed as having clinically active pulmonary tuberculosis were reviewed. Forty-nine patients (group I) were seropositives to human immunodeficiency virus (HIV), and 117 patients (group II) did not have known risk factors for HIV infection. Roentgenographic abnormalities were analysed in the two groups, according to nine different radiographic patterns previously defined. The seropositive group had a significantly higher proportion of hilar and/or mediastinal adenopathy ( P < 0.001), infiltrates confined to the lower lung fields ( P < 0.05), and miliary tuberculosis ( P < 0.005). Otherwise, single cavitation and destructive pattern were more frequent in the group II. These data suggest that patients with pulmonary tuberculosis and HIV infection are much more likely to have atypical radiographic findings.

Atypical radiographic findings in hepatic cavernous hemangioma: correlation with histologic features

Three cases of cavernous hemangioma of the liver having atypical imaging features are described. In the first case, an 11 x 10 cm hypervascular mass with a central hypovascular area supplied by many large tortuous vessels was demonstrated on angiography, CT, and sonography. The mass had a central cavity that contained fluid. In the second case there was a 2-cm isoechoic mass with a peripheral halo, despite the presence of typical features of hemangioma on angiography. The halo was shown histologically to be fibrous tissue surrounding the tumor. In the third case, a 6.5 x 4.3 cm mass exhibited slight peripheral enhancement on CT but was not detectable by angiography. Histologically, the tumor was hyalinized with only scattered small foci of hemangioma within it.

Persistent pulmonary abnormalities in newborns: the changing picture of bronchopulmonary dysplasia.

Significant changes in the radiographic features of bronchopulmonary dysplasia (BPD) have accompanied recent advances in treatment of neonatal respiratory distress syndrome. Retrospective study of 709 newborns showed atypical radiographic findings in many patients with clinical BPD. While 12/20 infants with clinical BPD showed changes identical to Northway's stage 4 disease, the remaining 8 (40% of patients with significant respiratory dysfunction) had diffuse, fine infiltrates without emphysema. Radiographic progression from RDS through all Northway stages was observed in only 4 patients. Diagnosis of stage 2 BPD was complicated by the presence of PDA in 9/17 cases. Stage 3 BPD was identified with certainty in only 5 infants, but may have coexisted with PIE in as many as 22 cases. Nevertheless, there was close agreement between the radiographic findings and clinical severity of chronic lung disease. Mild (type 1) infiltrates following RDS may be distinguished from chronic pulmonary insufficiency of prematurity (CPIP) or "immature lung." In patients who require only short-term supplemental O2, type 1 changes may reflect delayed resolution of RDS in an underdeveloped lung. These same findings in infants with prolonged O2 dependence usually indicate a mild form of BPD. Coarse infiltrates and emphysema (type 2) are almost always associated with severe respiratory impairment.